National Diabetes Work Programme

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1 National Diabetes Work Programme 2014/15 Released October

2 Citation: Ministry of Health National Diabetes Work Programme 2014/15. Wellington: Ministry of Health. Published in October 2014 by the Ministry of Health PO Box 5013, Wellington 6145, New Zealand ISBN (online) HP 5966 This document is available at This work is licensed under the Creative Commons Attribution 4.0 International licence. In essence, you are free to: share ie, copy and redistribute the material in any medium or format; adapt ie, remix, transform and build upon the material. You must give appropriate credit, provide a link to the licence and indicate if changes were made.

3 Contents i Overview and vision 1 Overview 1 Vision 1 Role of the Ministry of Health 2 Key principles of the National Diabetes Work Programme 2 National Diabetes Work Programme 2014/15 3 Prevention 4 Identification 5 Management 6 Enablers 7 Monitoring 8 Quality Standards for Diabetes Care 9 Basic care, self-management and education 9 Management of diabetes and cardiovascular risk (extensive guidelines available) 9 Management of diabetes complications (extensive guidelines available) 10 While in hospital Special groups 10 Additional information on Quality Standards for Diabetes Care 11 Prediabetes advice Identification of people with type 2 diabetes or prediabetes Lifestyle management of people with prediabetes Cardiovascular risk management 14 Notes 14 Reference 14 National Diabetes Work Programme 2014/15 iii

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5 Overview and vision Overview This document outlines the work programme of the Ministry of Health (the Ministry) diabetes team for 2014/15, including key priorities and the initiatives and objectives to achieve those priorities. It also shows the links across the Ministry s various teams and work programmes and how those links contribute to the diabetes team s priorities. The National Diabetes Work Programme brings together the work of the Ministry, National Diabetes Service Improvement Group (NDSIG), Health Quality & Safety Commission, district health boards (DHBs) and primary health organisations (PHOs) to implement the Government s priorities for diabetes. Non-communicable diseases such as diabetes, cardiovascular disease and cancer are the leading causes of mortality in New Zealand. The Ministry will work closely with the social sector and other sectors to influence New Zealanders decisions about how to improve their own health. The Ministry continues to seek to prevent the onset and impact of non-communicable diseases through more regular health checks relating to diabetes and cardiovascular disease and the risk factors for both these diseases. Vision People living with diabetes are regarded as leading partners in their own care within systems that ensure they can manage their own condition effectively with appropriate support. Health services for people with diabetes in New Zealand will be high-quality, patient-focused and integrated across the health continuum from prevention to tertiary care. In this way, they will reduce the diabetes burden and enable optimum health outcomes. National Diabetes Work Programme 2014/15 1

6 Role of the Ministry of Health The Ministry s diabetes team is the essential link between diabetes policy and frontline service improvements for patients. Through its integrated work programmes across the Ministry and by coordinating with other government agencies, it provides national leadership and direction and supports local voices championing good-quality diabetes care. The Ministry s diabetes team works with the National Diabetes Service Improvement Group (NDSIG), a Ministry-funded group of experts, whose members include health consumers. It s current key workstreams focus on: prevention and prediabetes complications of diabetes inpatients with diabetes workforce requirements and development health system performance self-management patients with type 1 diabetes, and children and young people. Key principles of the National Diabetes Work Programme The aim of the work programme is to focus service delivery on enhancing care and quality of life for people with diabetes. The work programme assumes that the focal point of care remains in primary care and the community setting, and that this work is supported by integrated primary health care teams and specialist health services. The work programme follows three key principles: 1. prevention 2. identification 3. management These key principles are underpinned by enablers and monitoring to support the implementation of the work programme. Work programme goals are to: 1. prevent: limit and reduce the risk of developing diabetes 2. identify: reduce the risk of developing complications for those New Zealanders with diabetes 3. manage: reduce the risk from complications of diabetes where they exist 4. enable: support and develop systems to provide high-quality care for people with diabetes 5. monitor: continually improve diabetes services to ensure equity of access and quality care. Prevention Identification Management Enablers Monitoring People with diabetes Systems 2 National Diabetes Work Programme 2014/15

7 National Diabetes Work Programme 2014/15 Prevention More Heart and Diabetes Checks Green Prescription prediabetes contracts Albert Street Medical Centre evaluation Healthy Families New Zealand NDSIG prevention sub-group Three prediabetes pilots Māori pilots People with diabetes Identification More Heart and Diabetes Checks Early identification of complications Retinal screening Chronic kidney disease Management DCIP implementation Podiatry Psychology and depression Self-management support and education Screening at admission to hospital Podiatry assessment tool Gestational diabetes guidelines Inpatients Chronic kidney disease Cardiovascular risk management Dietetics and nutritional support Systems Enablers 20 Quality Standards For diabetes care and toolkit Virtual diabetes register Systematic audit IT infrastructure Service specifications NDSIG Innovation sharing to support quality improvement Gap analysis of the Standards Monitoring More Heart and Diabetes Checks World Health Organization reporting OECD reporting Quarterly reporting (PP20) DHB visits Annual planning ASH rates Health Safety & Quality Commission Diabetes Atlas of Variation National Diabetes Work Programme 2014/15 3

8 Prevention Being overweight significantly increases an individual s chance of developing type 2 diabetes. The Ministry is coordinating several programmes of work looking at policies that influence lifestyle changes such as diet and physical activity. Initiatives More Heart and Diabetes Checks health target Evaluation of a prediabetes pilot at Albert Street Medical Centre Deliverables 90 percent of the eligible population will have had their cardiovascular risk assessed in the last five years. Contract for the evaluation of the prediabetes programme at Albert Street Medical Centre. Distribute lessons learnt following completion of the evaluation. Develop and distribute options to make the model transferrable to other DHBs and their populations. Prediabetes pilots Contract for three prediabetes pilots: Health Hawke s Bay, Harbour Sport and Sport Bay of Plenty. Monitor contracts regularly. Distribute lessons learnt from pilots following completion of evaluation. Māori pilots Conclude contract with the four Māori pilots. Evaluate the Māori pilots. Distribute lessons learnt following the evaluation. Green Prescription Contract with providers to deliver Green Prescriptions. Healthy Families New Zealand Begin 10 community pilot sites, which will reach approximately 900,000 New Zealanders. 4 National Diabetes Work Programme 2014/15

9 Identification As with other long-term conditions, early identification of diabetes allows people the opportunity to manage their diabetes before it becomes out of control. This management includes the early identification of complications such as foot ulceration, kidney damage and eye disease. When the early signs of damage to feet, kidneys and eyes are detected, active treatment can be undertaken to reduce the risk of amputation, renal failure, blindness, heart attack and stroke. There are encouraging signs that the rates of these complications in people with diabetes have been falling over recent years. Similarly there are new guidelines for gestational diabetes aiming for improved and earlier detection of both established and gestational diabetes. Initiatives More Heart and Diabetes Checks health target Deliverables 90 percent of the eligible population will have had their cardiovascular risk assessed in the last five years. Podiatry assessment tool Disseminate podiatry assessment tool to the health sector. Retinal screening Update retinal screening guidance. Chronic kidney assessment Disseminate chronic kidney consensus statement to the health sector. Gestational diabetes Implement the guidelines. National Diabetes Work Programme 2014/15 5

10 Management Effective management of diabetes and its complications gives people with diabetes the opportunity to lead normal lives. Management of diabetes includes prevention and early identification of diabetesrelated complications. Diabetes Care Improvement Packages (DCIPs) were introduced in July 2012 to replace the Get Checked programme. The introduction of DCIPs meant a change from a universally funded annual review process to a more tailored and individualised approach to diabetes care and management. This approach to diabetes care aims to empower people with diabetes to take an active role in their own care planning, and to ensure the delivery of patient-centred care. The Ministry is working closely with DHBs to ensure the continued implementation of the DCIPs and related quality improvement in diabetes services. Initiatives Deliverables Inpatients with diabetes Provide national guidance on diabetes to inpatients. Provide guidance for care planning and discharge information. Provide national guidance on diabetes ketoacidosis. Provide guidance on insulin safety in hospitals, in conjunction with the Health Safety & Quality Commission. Self-management support and education Pilots for new model of care promoting shared care Disseminate guidance on diabetes self-management support to the health sector and key stakeholders. Three pilots, which began in May 2014, are trialling a model of care focused on patient empowerment and change management in primary care for people with chronic disease. These pilots are due for evaluation in August Lessons learnt will be evaluated following evaluation. Podiatry Finalise the accreditation of training programme for community podiatrists and continue to work with Podiatry NZ on rolling out this programme nationally. Develop podiatry pathways. Develop podiatry models of care. Retinal screening Revise retinal screening guidance. Develop a model of care for retinal screening. Psychology Investigate the Diabetes Attitudes Wishes and Needs (DAWN) study to support people with diabetes and their whānau. Carry out a stocktake of assessment tools currently used to support psychological needs. 6 National Diabetes Work Programme 2014/15

11 Enablers Enablers such as service specifications provide the mechanism for making improvements in key priority areas of prevention, identification and management. Initiatives 20 Quality Standards for Diabetes Care (the Standards) Development of toolkit to support the Standards Deliverables Disseminate Standards to the health sector. These Standards will form part of DHB annual planning guidance and DHB service specifications. Develop toolkit to support the Standards. This will include academic rationale, innovation and implementation advice. Gap analysis Conduct a stocktake of current services against the 20 Standards to form a baseline for evaluation. Service specifications Review DHB service specifications and, in the long term, develop an overarching DCIP service specification. Framework for diabetes contracting Develop monitoring framework to support the Standards and outcomes. Virtual diabetes register (VDR) Run the VDR for 2013 and 2014 then disseminate results to the health sector. Improving the patient experience Conduct focus groups to identify areas where the patient experience could be improved. Development of case studies Develop six case studies to highlight innovation and patient stories. Ministry of Health website Update diabetes page. Innovation resource sharing centre Update diabetes page on the Health Improvement and Innovation Resource Centre website. National Diabetes Work Programme 2014/15 7

12 Monitoring By monitoring the health system, the Ministry gains a clear understanding of services being provided to people with diabetes. Based on this understanding, it can then provide support for quality improvements and share lessons learnt from stories of success across the health sector. There is currently inconsistency and inequity in the access to, availability of and quality of diabetes services between DHBs and PHOs. These issues will be addressed using the following tools and frameworks. Initiatives More Heart and Diabetes Checks health target Deliverables 90 percent of the eligible population will have had their cardiovascular risk assessed in the last five years. DHB annual plans Review and agree timeframes and deliverables against advice provided. DHB annual planning advice Develop annual planning advice for 2015/16. Quarterly reporting (PP20) Monitor progress of DHBs against annual plan deliverables. DHB visits Visit DHBs six monthly. Health Safety & Quality Commission Diabetes Atlas of Variation Reporting to the World Health Organization and Organisation for Economic Co-operation and Development (OECD) Ambulatory sensitive hospitalisation (ASH) rates for diabetes The Atlas, shortly to be published, shows many diabetes metrics by individual DHB. The Atlas will be used as a quality improvement tool to measure progress in quarters 2 and 4. Collate diabetes-related data to inform reporting to the World Health Organization and OECD. Collate rates and trends of ASH and report back to DHBs as a quality improvement measure. Clinical governance Identify and disseminate examples/models of successful local clinical governance. Coding of prediabetes Share advice with the health sector. 8 National Diabetes Work Programme 2014/15

13 Quality Standards for Diabetes Care For revision at end of 2016 These Standards should be considered when planning your local service delivery. They provide guidance for clinical quality service planning and implementation of equitable and comprehensive patientcentred care scaled to local diabetes prevalence. They should be read alongside the New Zealand Guidelines Group (NZGG) guidelines and other guidelines that highlight specific clinical expectations. These Standards are specific to people with diabetes; those identified with prediabetes should be managed in accordance with the prediabetes advice provided by the Ministry of Health (2013). Basic care, self-management and education 1. People with diabetes should receive high-quality, structured self-management education that is tailored to their individual and cultural needs. They and their families and whānau should be informed of, and provided with, support services and resources that are appropriate and locally available. 2. People with diabetes should receive personalised advice on nutrition and physical activity, together with smoking cessation advice and support if required. 3. They should be offered, as a minimum, an annual assessment for the risk and presence of diabetesrelated complications and for cardiovascular risk. They should participate in making their own care plans, and set agreed and documented goals/targets with their health care team. 4. They should be assessed for the presence of psychological problems, with expert help provided if required. Management of diabetes and cardiovascular risk (extensive guidelines available) 5. People with diabetes should agree with their health care professionals to start, review and stop medication as appropriate to manage their cardiovascular risk, blood glucose and other health issues. They should have access to glucose monitoring devices appropriate to their needs. 6. They should be offered blood pressure, blood lipid and anti-platelet therapy to lower cardiovascular risk when required in accordance with current recommendations. 7. When insulin is required, it should be initiated by trained health care professionals within a structured programme that, whenever possible, includes education in dose titration by the person with diabetes. 8. Those who do not achieve their agreed targets should have access to appropriate expert help. National Diabetes Work Programme 2014/15 9

14 Management of diabetes complications (extensive guidelines available) 9. All people with diabetes should have access to regular retinal photography or an eye examination, with subsequent specialist treatment if necessary. 10. They should have regular checks of renal function (egfr) and proteinuria (ACR), with appropriate management and/or referral if results are abnormal. 11. They should be assessed for the risk of foot ulceration and, if required, receive regular review. Those with active foot problems should be referred to and treated by a multidisciplinary foot care team within recommended timeframes. 12. Those with serious or progressive complications should have timely access to expert/specialist help. While in hospital People with diabetes who are admitted to hospital for any reason should be cared for by appropriately trained staff, and provided with access to an expert diabetes team when necessary. They should be given the choice of self-monitoring and encouraged to manage their own insulin whenever clinically appropriate. 14. Those admitted as a result of uncontrolled diabetes or with diabetic ketoacidosis should receive educational support before discharge and follow-up arranged by their general practitioner and/or a specialist diabetes team. 15. Those who have experienced severe hypoglycaemia that requires them to attend an emergency department or be admitted to hospital should be actively followed up and managed to reduce the risk of recurrence and readmission. Special groups 16. Young people with diabetes should have access to an experienced multidisciplinary team, including health professionals with expertise in development, youth health, health psychology and dietetics. 17. All patients with type 1 diabetes should have access to an experienced multidisciplinary team, including health professionals with expertise in insulin pumps and the continuous glucose monitoring system (CGMS) when required. 18. Vulnerable patients, including those in residential facilities and those with mental health or cognitive problems, should have access to all aspects of care, tailored to their individual needs. 19. Those with uncommon causes of diabetes (eg, cystic fibrosis, monogenic, post-pancreatectomy) should have access to specialist expertise with experience in these conditions. 20. Pregnant women with established diabetes and those developing gestational diabetes (GDM) should have access to prompt expert advice and management, with follow-up after pregnancy. Those with diabetes who are of childbearing age should be advised of optimal planning of pregnancy including the benefits of preconception glycaemic control. Those not wishing for a pregnancy should be offered appropriate contraceptive advice as required. 10 National Diabetes Work Programme 2014/15

15 Additional information on Quality Standards for Diabetes Care The Ministry s diabetes team, working in conjunction with clinical leaders and the National Diabetes Service Improvement Group, has developed 20 Quality Standards for Diabetes Care (the Standards). These Standards have been developed to help DHBs in planning and funding the delivery of their diabetes services and to ensure high-quality and equitable service provision across New Zealand. The Standards are separated into five categories: 1. Basic care, self-management and education 2. Management of diabetes and cardiovascular risk 3. Management of diabetes complications 4. While in hospital Special groups. The diabetes team will continue to work with NDSIG to develop a toolkit to support the implementation of the Standards. While the majority of the Standards address the management of diabetes care, they fit into the various work streams of the diabetes team s work programme, as illustrated in the diagram below. People with diabetes Prevention Relevant Standard Special groups Standard 20 Identification Relevant Standards Basic care, self- management and education Standard 3 Management of diabetes and cardiovascular risk Standards 5 and 7 Management of complications Standards 9 12 Management Relevant Standards Enablers and Monitoring: Work coordinated by the Ministry s diabetes team to implement the 20 Quality Standards for Diabetes Care. Basic care, self-management and education Standards 1 4 Management of diabetes and cardiovascular risk Standards 5 8 Management of diabetes complications Standards 9 12 While in hospital Standards Special groups Standards National Diabetes Work Programme 2014/15 11

16 Prediabetes advice 1. Identification of people with type 2 diabetes or prediabetes Screening for hyperglycaemia is undertaken as part of cardiovascular risk assessment according to national guidelines (see Table 1, page 4 in New Zealand Guidelines Group 2012). In addition, the New Zealand Society for the Study of Diabetes has endorsed the need for opportunistic screening among younger adults (those over 25 years) who are known to be at especially high risk of developing diabetes. The screening includes: those with known ischaemic heart, cerebrovascular or peripheral vascular disease those on long-term steroid or anti-psychotic treatment obese individuals (BMI 30; or BMI 27 kg/m 2 for Indo-Asian people) people with a family history of early- age onset of type 2 diabetes in more than one first-degree relative women with a past personal history of gestational diabetes mellitus obese children and young adults (BMI 30 kg/m 2 ; or 27 kg/m 2 in Indo-Asian) if there is a family history of early onset type 2 diabetes, or if they are of Māori, Pacific or Indo-Asian ethnicity women with polycystic ovarian syndrome (PCOS). Haemoglobin A1c (HbA1c) is the recommended screening test for diabetes and prediabetes. While it is acknowledged that increasing levels of HbA1c are associated with a continuous gradient of risk of progressing to diabetes, those with HbA1c levels in the range mmol/mol are considered to have prediabetes, 1 otherwise known as intermediate hyperglycaemia. Impressive evidence from many randomised controlled trials indicates that the risk of progression from prediabetes to diabetes can be substantially reduced through lifestyle modification or, to a lesser extent, with drug treatment. Additionally, the fact that cardiovascular risk rises with increasing levels of HbA1c further justifies intervention in people with prediabetes. Rates of prediabetes in New Zealand vary according to age, sex and ethnicity but the overall prevalence among New Zealand residents aged 15 years and over is about 25 percent. 12 National Diabetes Work Programme 2014/15

17 2. Lifestyle management of people with prediabetes Randomised controlled trials have confirmed the potential of lifestyle modification to approximately halve the risk of progressing from prediabetes to type 2 diabetes over a prolonged period. The following principles can help in providing advice to individuals. Principles of initiating change Changing eating and activity patterns and lifelong habits is not easy. Assess willingness to change. Encourage people to make one change at a time. Start with small, achievable goals, especially those that are expected to give the greatest benefit. Inform people about what foods contain sugar and hidden fat. Encourage and congratulate even the smallest success. Create an agreed plan, including follow-up, with the individual. Reducing weight Weight reduction is the most important target for most people with prediabetes. For most people, following healthy eating guidelines and increasing exercise will achieve weight loss. If the patient is overweight or obese, aim for a weight loss of kg per week and a long-term loss of at least 5 percent of initial weight but acknowledge any degree of loss as a success. Staying the same weight may be a meaningful achievement for some individuals. Follow the healthy eating guidelines Eat three meals a day including 5+ serves of fruit and vegetables. Reduce sugary foods and drinks by: substituting cakes, biscuits and snack foods with fruit drinking water instead of fizzy or sugary drinks. Reduce fat by: using low-fat dairy products (eg, skimmed or calci-trim milk, low-fat yoghurts) limiting fried foods and takeaways to once a week or less avoiding food with hidden fat (eg, pies, pastries, chippies). Have smaller portion sizes use a smaller plate. Increase exercise Consider a Green Prescription. Aim for 30 minutes of moderate-intensity exercise such as brisk walking on most days; when possible, increase exercise time to 60 minutes per day. Snacks of exercise may be a good alternative, for example 3 x 10 minutes during the day. Help the individual find an activity that fits in with their lifestyle and is sustainable. Undertaking exercise with others is often more enjoyable. Any increase in activity, however small, is a positive step. Reduce inactivity avoid sitting for extended periods eg, while watching TV (even standing uses more energy). National Diabetes Work Programme 2014/15 13

18 Follow-up Follow-up needs to reflect the goals and plan agreed with the person, particularly with lifestyle interventions. Initial HbA1c should be repeated after three months of lifestyle therapy and thereafter at intervals of 6 to 12 months, as should measures of weight, dietary and exercise changes. Treatment with metformin should be considered after 6 to 12 months for those whose HbA1c levels continue to rise despite attempts to make lifestyle changes, or when levels are close to the cut-off level for diabetes and are not falling (ie, mmol/mol). Self-monitored blood glucose (SMBG) measurement and retinal screening are not indicated for people with prediabetes. Drug treatment Metformin is the only drug currently recommended for the routine management of prediabetes. It is an adjunct, not an alternative, and is less effective alone than lifestyle change. It is important to consider this in the context of cardiovascular risk. It is usually best to start with a low dose (500 mg daily or twice daily with food) and increase gradually as tolerated, if required, to g/day in divided doses. Metformin should always be taken with food and, if patients are intolerant, can be initiated at a dose of 250 mg/day. Support to achieve lifestyle and weight loss goals should continue. 3. Cardiovascular risk management Cardiovascular risk assessment and active management should still be carried out as per the New Zealand Guidelines Group (2012). Cardiovascular risk is the greatest threat to the patient s short- and medium-term health, irrespective of whether they progress to type 2 diabetes. Notes These interim recommendations were written by Professor Jim Mann and Dr Kirsten Coppell with input from Dr Paul Drury, Dr Helen Rodenburg and Ann Gregory on behalf of the National Diabetes Services Improvement Group(NDSIG). Where this advice is being used in systematic prediabetes programmes in practices, PHOs and DHBs, it is strongly recommended that contact is made with the Ministry of Health to ensure data collection and outcome measures/evaluations are compatible with other such projects. Reference New Zealand Guidelines Group New Zealand Primary Care Handbook rd ed. Wellington: New Zealand Guidelines Group. 14 National Diabetes Work Programme 2014/15

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